Ambulance Dispatch Report

Please complete this report and submit it to the North Dakota Department of Health
when there has been an irregularity in the dispatch process for ambulance services.
The Department of Health will use this information to better understand and improve
the performance of the EMS system in North Dakota. Examples of irregularities include;
non-response from an ambulance service, delayed response (30 minutes or more from
time of dispatch to en route time), or any other reason that the dispatch process
was unusual, confusing, or degraded.

Report Type:No ResponseDelayed ResponseOther (explain below)

Incident Date:

Incident Type:

Nature of Call:

Ambulance Service Dispatched:

Dispatch Time (military):

En route Time (military):

Was there another service dispatched?YesNo

If so, list second ambulance service dispatched.

Second Ambulance
Dispatch Time (military):

Second Ambulance
En route Time (military):

Was the patient transported by an ambulance?YesNo

Please briefly describe what occurred (including any communication with the ambulance
crew).